NCC230045_FRO Submitted_20230111

Submit to the Water Resources Department, 316 N. Academy St., Cary, NC 27513
Town of Cary
Water Resources Department
Financial Responsibility - Ownership Form
No person may initiate any land -disturbing activity covered by the Town of Cary Sedimentation and
Erosion Control Ordinance before completing and filing this form with the Town of Cary Stormwater
Division. Indicate NIA if a question is not applicable.
PROJECT NAME CROSSROADS CHICK-FIL-A
PROJECT LOCATION
1825 WALNUT STREET, CARY, NC 27518
APPROXIMATE DATE OF PROJECT INITIATION
ACREAGE OF LAND TO BE DISTURBED
me:
PERSON(S) OR FIRM(S) FINANCIALLY RESPONSIBLE FOR THIS LAND -DISTURBING ACTIVITY: (If
out of state, a registered agent in North Carolina must be used.)
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Name (Person or Firm)
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Street Address (No PO Sox)
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City State Zip
33e, 5 •� �
Telephone Number
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FaNumber
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E-Mail Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
Name
Address (No PO Box)
City State Zip
Telephone Number
Fax Number
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TOWN of CA RY
316 North Academy Street a Cary, NC 27513 • PO Box 8005 + Cary, NC 27512-8005
te1919-469-4030 • fax [phone] • wwvv.torvnofcary.org

The Town reserves the right to contact either the financially responsible person or registered agent listed
below in case of violation. Please indicate your preference below.
Gpx.-6a(x-r sLAccA— OR
Financially Responsible Person Registered Agent
THE ABOVE INFORMATION Is true and correct to the best of my knowledge and belief and as provided
by me while under oath. (This form must be signed by the financially responsible person if an individual or
by an officer, director, partner, attorney -in -fact, or other person with authority to execute instruments for
the financially responsible person if not an individual.
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Title orAuthority
11/17/22
North Carolina
I L'Fop-b- — County
(-Aj2q,&& "QbAp� , a Notary Public for C=>U%LjV:nkj.'�k County, North Carolina, do
hereby certify that RAC4tA - personally came before me this day and acknowledged
that he is ki P Of aEg&jL)j$ and acknowledged, on behalf of
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6R6t lVi 1*1lr the due execution of the foregoing instrument.
Witness my hand and official seal, this the _L:r%% day of _hamMBEZ, 20ag .
Gloria A. Thompson
Notary Public
Guilford County
North Carolina
My Commission Expires
Notary Public
My commission expires &R`?A)W—A 9 , 20 ol�.
TOWN Of CARY
316 North Academy Street * Cary, NC 27513 * PO Box 8005 * Cary, NC 27512-8005
tel [phone] e fax [phone] & "rw.tw.%,nofcary.org
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